Credit Card/Debit Card Authorization Form - New York

Daytime telephone number: Fax number:
Credit Card Number:
NYS Department of State
DIVISION OF CORPORATIONS
Credit Card/Debit Card Authorization
One Commerce Plaza, 99 Washington Ave.
Albany, NY 12231-0001
www.dos.ny.gov
Attach this form to your document or written request.
The Name of Corporation or Other Business Entity To Which This Service Request
Applies is:
Check Box for Requested Service: Fill in Fee or Amount:
(Consult appropriate fee schedule for filing fees)
Routine Service (No Charge), OR Expedited Service:
(The fee for each certified copy is $10.)
(The fee for each plain copy is $5.)
(Certificates of Good Standing, etc. The fee for each certificate is $25.)
(Must be served in person at the above address)
Account Name:
Account Number:
TOTAL (Total Amount Due):
*Same day expedited service requests must be received by 12 noon.
**2-hour expedited service requests must be received by 2:30 p.m.
Expedited service fees are non-refundable and will not be refunded if a filing is rejected.
Expiration Date (Month and Year):
Name as it Appears on Credit
Card or Debit Card (Print):
Cardholder’s Billing Address (As listed
with Credit Card or Debit Card Company):
City: State: Zip Code+4:
Cardholder’s Signature:
Date:
If the name on the credit card or debit card is in the name of a
corporation or other business entity, please print the signer’s name:
DOS-1515-f-l (Rev. 05/13)
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Credit/Debit Card Information:
24-Hour-$25 *Same-Day-$75 **2-Hour-$150
MasterCard Visa American Express
FILING OF DOCUMENTS AND CERTIFICATES
CERTIFIED COPY
PLAIN COPY
CERTIFICATE UNDER SEAL
SERVICE OF PROCESS
BIENNIAL / FIVE YEAR STATEMENT
OTHER
DEPOSIT TO DRAWDOWN
(Clears all text entry fields)
Routine Service (No Charge), OR Expedited Service:
24-Hour-$25 *Same-Day-$75 **2-Hour-$150
Routine Service (No Charge), OR Expedited Service:
24-Hour-$25 *Same-Day-$75 **2-Hour-$150
Routine Service (No Charge), OR Expedited Service:
24-Hour-$25 *Same-Day-$75 **2-Hour-$150
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Credit Card/Debit Card Authorization Form - New York PDF

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